How rooming in helps moms and babies

Fifteen years ago, a friend of mine had her first baby at a prestigious Boston hospital. She was a resident in Ob/Gyn at the time, and a long labor ultimately ended with a c-section, and a healthy newborn boy. That evening, when she, her baby, and her husband were in their postpartum room, the nurse entered.

“It’s time to take the baby to the nursery!” she said.

My friend looked confused. “We’re planning to keep him in the room with us tonight.”

The nurse frowned. “Well, who’s going to take care of him? You just had a c-section.”

My friend gestured to her husband, who was sitting on the couch.

The nurse frowned again. “Well, you know these c-section babies can get a little junky,” she said, alluding to the mucous that babies not born vaginally sometimes cough up.

The nurse shrugged. “Well, you’re a doctor. I guess if he aspirates, you can resuscitate him.” And she walked out of the room, shaking her head.

My friend used to tell this story, laughing darkly, as she recalled how she thought perhaps she should ask for the code cart to be wheeled into the room, just in case.

For the record, baby spent an uneventful night in mom’s room. But the routine separation of moms and babies – as well as other practices that have been shown to make it harder for families to get started breastfeeding – remains the default in many maternity centers in the US. Less than half of US hospitals provide routine rooming in for healthy moms and babies.

That’s bad news for babies, and it’s bad news for mothers, because these out-of-date practices make it harder for women to achieve their own breastfeeding goals. A study of nearly 2000 US mothers found that among mothers who received six of six best practices for maternity care, 97% achieved their personal goal to breastfeeding for at least 6 weeks. Among mothers who received zero of six, nearly 30% failed to achieve their personal goals.

These practices – the World Health Organization Ten Steps to Successful Breastfeeding – have been shown to be effective in a randomized controlled trial, which is the gold standard for medical evidence. In the PROBIT study, researchers randomized 31 hospitals to the Ten Steps or to continuing usual care. The study enrolled 17,046 mother-infant pairs, all of whom intended to breastfeed. Dyads who received care in a Ten Steps hospital were more likely to be exclusively breastfeeding at 3 months (43.3 vs. 6.4%) and to be breastfeeding at 12 months (19.7 vs. 11.4%). Ten Steps care has a lasting impact on breastfeeding success.

To address this gap, Healthy People 2020 made increasing the number of infants born in Ten Steps hospitals a public health goal, and the CDC has funded a national collaborative to assist hospitals in implementing best practices. So what’s not to like? Well, a great deal, based on recent coverage of efforts to implement the Ten Steps. A recent article in the Boston Globe took issue with the move away from nurseries, calling them “long a life raft for recovering mothers,” and stated that new moms “often are surprised to learn that Massachusetts hospitals are increasingly restricting nursery access.” The account quoted 5 mothers unhappy with rooming in, before a single positive anecdote, buried 1,348 words into the 1,964-word article.

The article did not address research on rooming-in and breastfeeding, or rooming-in and sleep quality. Evidence from randomized controlled trials shows that rooming in helps moms and babies breastfeed successfully. In a study comparing infants randomized assigned to rooming-in vs. nursery care, babies who were kept in the nursery received significantly more formula and significantly less breast-milk. Moreover, evidence suggests that mothers who send their babies to the nursery do not sleep longer or better than mothers who have their babies room in. And babies sleep better in the mother’s room than in a nursery setting.

Most importantly, implementing the Ten Steps ensures that all mothers are supported to initiate and sustain breastfeeding, regardless of their age, race, or ethnicity. When breastfeeding is perceived as the domain of privileged, highly educated women, hospital staff may offer rooming-in to “the kind of women who breastfeed,” but not to “the kind of women who formula feed.” Indeed, a CDC study found that maternity facilities in zip codes with > 12.2% black residents were less likely to provide Ten Steps care than facilities with zip codes with ≤ 12.2% black residents, suggesting that disparities in care contribute to disparities in breastfeeding initiation, continuation, and, ultimately, disparities in health outcomes for mothers and babies.

However, rather than addressing these public health issues, the media coverage purports that there’s a battle being waged in hospitals between advocates for breastfeeding-über-alles and exhausted mothers denied any respite after childbirth. In fact, the guidelines for Ten Steps implementation from Baby Friendly USA support each mother’s informed decision to use the hospital nursery. The key to understanding this policy is that facilities should provide rooming-in as the standard for mother-baby care. “Standard” means that nurses will not routinely remove babies from mothers’ rooms in the evening, but will instead provide each mother with support and assistance so that she can learn how to care for her infant.

Importantly, “standard” does not mean “universal.” In my clinical practice, I regularly care for women with bipolar disorder, for whom the disruption of sleep in the early days postpartum can be catastrophic, triggering postpartum psychosis. We talk about the rationale for rooming in, and the reasons that it may not be optimal for her. And we document, in the medical record, that she will send her baby to the nursery to ensure a period of consolidated sleep immediately postpartum. That’s why Baby Friendly guidelines stipulate that at least 80% of healthy infants should be spending 23 hours a day with their mothers, unless there are medical reasons for separation. The 80% benchmark provides leeway for mothers and babies for whom rooming-in may not be optimal.

For the majority of moms, however, rooming-in has substantial advantages. In particular, having baby in the room at night is a crucial opportunity to teach families how to safely negotiate infant care, sleep and fatigue. In the absence of such guidance, tragic outcomes can occur. A troubling case series in the Journal of Perinatology documented 15 deaths and 3 near-deaths of healthy newborns sharing a sleeping surface with a parent during maternity stays between 1999 and 2013, a time period during which 61,204,386 infants were born in the US, or 2.9 events per million births. One infant was found wedged on a couch between parents; others were found limp in bed with their mothers. In each case, the author notes that there were one or more risk factors known to increase the risk of bed-sharing.

It’s tempting to simply move all the babies to the nursery at night to avoid these tragedies in the hospital. However, the postpartum stay lasts only a few days, and families need guidance for how they will manage fatigue and infant care in the days and weeks to follow. Rooming-in offers an ideal opportunity to teach families how to feed, soothe and settle infants safely, with support from experienced mother-baby providers.

With anticipatory guidance and support during the first few nights after birth, rooming-in will help the majority of moms and babies to thrive, with the flexibility to accommodate families who might need a different plan for care. Using the Ten Steps to set the standard for maternity care is good for moms and for babies.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician and breastfeeding researcher. She is an associate professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine and Distinguished Scholar of Infant and Young Child Feeding at the Gillings School of Global Public Health. You can follow her on Twitter at @astuebe.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

What support did you receive for night-time parenting during your maternity stay? What might have made your experience better? How might we assure that each family leaves the maternity center prepared for the complexities of fatigue, sleep, and infant care?

16 Responses

While the above argument is sound, it is based on the assumption nurseries still exist in all hospitals. Rooming-in was a wonderful experience with my first child but a hellish experience with my second due to pregnancy complications. The problem? Rooming-in policies had done away with the nursery entirely. I could barely hold my baby and there was zero help. The midwives urged me to call family to ask for help but no one was available. Expecting patients to supply their own crisis support instead of providing a nursery is hardly a good standard of care.

I’m sorry you had such a bad experience. Hospitals are not advised to close their nursery as part of the Baby Friendly Hospital Initiative in the US — as noted on the BFUSA web site:

“Baby-Friendly designated hospitals are not required to close their newborn nurseries. Rooming-in is an evidenced-based practice that is beneficial to both mothers and infants and is the routine standard of care. It is Baby-Friendly USA’s expectation that all practices associated with the Ten Steps to Successful Breastfeeding be implemented in a sensitive manner that is responsive to the family’s needs and follows the safety protocols of the facility.”

One of the challenges in implementing Baby Friendly is ensuring that staff understand that “standard” is not “universal.” It sounds like that balance was missing in your experience. Have you written to the hospital leadership to let them know? Patient perspectives have a powerful influence on policies and practices.

Thank you. I was not aware of this. My hospital was not in the US but hospitals in my country often follow the lead of the US. I would like to send them this information but I am already in conversation with them about other aspects of the baby-friendly initiative you addressed in one of your previous posts, which to me seem a more urgent priority (and more fixable than finding the physical space for a nursery). Perhaps I will raise this another time.

I am surprised and heartened to hear that Baby Friendly does not require rooming in. I do not think that the 80% rule is widely known—

NICHQ’s Best Fed Beginnings program (that works with baby friendly) really didn’t make it look like a nursery could EVER be a good thing in the following article. In this article, they encouraged hospitals to scare mothers away from using the nursery by placing warning signs on the door:

(in one hospital)…. “They put a self-proclaimed “scary” sign on the nursery door that reads: “Authorized Personnel Only. This space is reserved for flu isolation, MRSA isolation, urgent evaluation for sick newborns and procedures. Healthy newborns are assigned to rooms on the Family Beginnings unit. Please see your nurse for more information.”

I am sorry I am such a pest on this blog—but really you make it hard for me to keep my keyboard quiet.
I was just reading ABM protocol #19 on antenatal education through the link provided in Dr Steube’s article. It states,

“It is also important to determine any family medical
history that may make breastfeeding especially
helpful for this child (e.g., asthma, eczema, diabetes,
and obesity) and/or mother (e.g., obesity, diabetes,
depression, and breast or ovarian cancer).”

Seriously?? This was published in 2015.

There isn’t strong evidence that breastfeeding can protect against diabetes and obesity. Almost all well done research finds a very small effect if any.
There is very little to no evidence that breastfeeding can protect against eczema and asthma, and there are a few studies that find increased in asthma in eczema in BF babies.

Do you really want to push mothers who have family histories of these diseases extra hard to choose to breastfeed and succeed at it? Obese women and those with diabetes will have a harder time breastfeeding than the rest of the population, and breastfeeding has been named a risk factor for some atopic conditions.

Again, This protocol was last year. Does anyone at the ABM read the research? Does anyone there know the difference between causal relationship and association?

Will any academy members weigh in this? Every time I question the research on the I get silence, (except form Dr Bartick, who admitted that breastfeeding did not protect against diabetes asthma and eczema-but no changes have been made to your statements or protocols).

I challenge any of the authors of this protocol or members of the academy to find ONE original recent study that says that breastfeeding can reduce the risk of eczema. Below are several studies that do not find breastfeeding protective.

How about just making sure that experiences of mother and baby support her desire to breastfeed? That would be no unauthorized use of pacifiers or feeds with artificial milk, minimal separation of mom and baby, ready access to a lactation consultant, etc. Also, please no comment from a nurse or physician to indicate it does’t make any difference what baby eats, because it does make a difference for a host of reasons besides those you mention.
Give moms good information and institute practices that support their desire to breastfeed. That is not “pushing.” Of course, recognize that some research is inconclusive, But that does not result in policies that fail to inform, encourage and support the breastfeeding mom.

Dr. Steube, this is a very disappointing reductio ad absurdum argument. You imply that the only alternative to mandatory rooming in is mandatory return of all babies to the nursery. No doubt you know as well as I do that the alternative to mandatory rooming in is rooming in BY CHOICE.

Abolishing well babies nurseries has NEVER been shown to improve breastfeeding rates. How could it? Do you really mean to insinuate that new mothers are so unconcerned about their precious newborns that they make important feeding decisions based on whether they are forced to exhaustion by being unable to let someone else care for their babies no matter how briefly?

Why don’t you trust women to make the CHOICE that is right for them? It is deeply anti-feminist to insist that women should be deprived of choice because you and your colleagues in the breastfeeding industry know better than they what is right for them and their families.

Please tell me, Dr. Stuebe, what’s the difference between anti-choice activists who mandate absurd barriers to pregnancy termination under the guise of what’s best for women and the breastfeeding industry that mandates absurd barriers to formula feeding under the guise of what’s best for babies.

Why do the same women who believe fervently that women have the right to control their own bodies, and that no one should be condemned for choosing abortion ignore the fact that women have the right to control their breasts and shame them for formula feeding?

Where are the vaunted benefits to breastfeeding? Breastfeeding rates have tripled in the past 50 years, yet lactivists appear to be unable to indentify even a single term baby whose life was saved by breastfeeding, nor a single healthcare dollar that was saved because a term baby was breastfed instead of formula fed. Please don’t offer extrapolations from small studies riddled with confounders. Show me US based population data. There isn’t any, right?

Please explain why it is reasonable or appropriate to deprive women of choice by mandating rooming in or why it is reasonable or appropriate to aggressively promote breastfeeding when there is no US population based evidence that it saves lives or saves money.

I will add that I had three babies, at three different hospitals in the Seattle area. None of the hospitals had a nursery that healthy babies were allowed to use. I stayed alone in the hospital each time. My first 24 hours as a new mom were terrible all three times. I was totally committed to breast feeding and I don’t think 2-3 hours of consolidated sleep would have changed that. Getting out of bed to get a baby, catheter in place, fresh c-section scar, several times per night is a horrible memory. The hospital beds are likely the most unsafe co-sleeping space, the bassinettes just awkward enough that you can’t safely stay in bed and grab the baby. I honestly get tearful remembering it.

I had a rough start with breast feeding with each of my deliveries, but was eventually able to exclusively breast feed after a short period of supplementation. I think rooming in likely made things more difficult – I was left adrift to work on feeding.

Rooming in is a financial boon for hospitals, and great for the staff. I am skeptical of the evidence that it is right for most moms.

I think it’s ridiculous that in 2016 we aren’t listening to what each mom actually wants and needs, instead of feeding them “scripted” information that Baby-Friendly Hospitals are famous for shoving down patients’ throats. Our moms understand that breast is best! They’re not stupid! And claiming that breastfeeding will protect your child against all these diseases that breastfeeding hasn’t been proven to protect against is irresponsible! News flash, both breast and bottle fed infants get these diseases. Genetics, what the child eats after infancy, and environment all play a role in these diseases. Let’s also mention that most of this data that people who are pushing this Baby-Friendly use as “gospel” is very outdated, from the 1990’s. And you also can’t make cause and effect conclusions from it. You can’t make the conclusion that pacifier use results in decreased breastfeeding numbers. Let’s stop painting breastfeeding like it’s this magic ingredient that will protect kids against everything, and let’s stop painting formula like it’s this poison that will make your infant sick. Let’s stop forced rooming-in as well. Let’s stop pretending that these exhausted moms won’t bond well or be able to breastfeed their infants. None of these things are true! Listen to patients who are writing articles, blogging, and making comments online about how dissatisfied they are with the changes Baby-Friendly Hospitals are making. Yes, some hospitals are getting rid of their nurseries, probably so the big, bad nurses aren’t tempted to listen to moms and take the babies to the nursery until the next feeding. If you have no nursery, the big, bad nurses can’t use it! Nurses listen to their patients unless they’re forced to do things like forced rooming-in. Nursing jobs have been threatened over nursery usage! Even if a hospital still has a nursery, 80% of moms have to room in 23 hrs a day to be a designated Baby-Friendly Hospital. Therefore, you’re forcing lots of moms to room-in who don’t want to simply to get this ridiculous Baby-Friendly designation. I guarantee that 80% of moms in the US do not want to room in! Therefore, we have to force them to room-in to have Baby Friendly Hospitals in this country! These steps have not proven to raise breastfeeding rates by the way. What they’ve done is make a majority of maternity patients VERY unhappy. Those moms who want to room-in at night are in the minority in the US. And these moms are always welcome to room-in if they wish! In other many of these other countries, women don’t have the choice of a nursery. When these foreign moms deliver in the US, they use our nursery! Nurses know this from experience. Let’s stop forcing moms to do things in the name of the Baby-Friendly Initiative. Let’s let moms do what they want to do, and let them do what works for them during their hospital stay, and stop forcing them to do anything!

Hospitals actually have to pay to be designated as Baby-Friendly. They also have to start paying for formula. There is no financial incentive to becoming Baby Friendly. It is not good for the staff either. The staff on these floors generally do not like operating in an environment where you deny patients the help they ask for or need (a nursery). The only reason hospitals are going Baby Friendly is because enough people in positions that have influence in these hospitals are buying the bogus data that these 10 steps will increase breastfeeding rates and make our children healthier. And it’s also becoming “the thing” to do. Hospitals are trying to become Baby Friendly because all other hospitals in the area are doing this as well.

The truth is that the BFHI has good intentions but very bad unintended results. I’ve twice given birth in hospitals that practiced BFHI policies, like mandatory rooming-in and no pacifiers (grudgingly being given a pacifier after begging for one is not one of my happiest memories). The mandatory rooming-in was hellish for me, particularly after the birth of my second child. We were a military family with no one nearby to help us, living in a remote part of the country. My husband had to go home to take care of our first child, and I had pre-eclampsia and so was woozy from the medications I was given to control my blood pressure. Nevertheless, I was expected to be the exclusive caregiver for my newborn child from hour one, including through two overnight stays. She was in a high bassinet, which made it difficult for me to get her. And she wouldn’t sleep unless I held her. The second night, after 48 hours with no sleep, I fell asleep while nursing her, and dropped her. I woke up just in time to catch her, but I was terrified and begged to be discharged from the hospital early so that it wouldn’t happen again. So that’s the result of the BFHI for me: a near-miss that could have resulted in injury or death to my infant daughter, and my determination to leave the hospital despite continued very high blood pressure readings. I was going to breastfeed my daughter no matter what. A few hours in the nursery while I slept would not have changed the way I fed her, and would have made all the difference to my well-being and to her safety.
The BFHI is paternalistic and not evidence-based. Mothers should be able to choose how they feed their babies, and they should be able to send their babies to the nursery if they (the mothers) need to. The end.